ICD-10 Guide

Acute Deep Venous Thrombosis

ICD-10 Coding for Acute Deep Venous Thrombosis(I82.401, I82.421)

PRIMARY SPECIALTYEmergency Medicine

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Acute Deep Venous Thrombosis?

Acute Deep Venous Thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, most commonly in the legs. Key clinical points include: 1) DVT can lead to serious complications such as pulmonary embolism; 2) Risk factors include prolonged immobility, surgery, and certain medical conditions; 3) Symptoms may include swelling, pain, and redness in the affected limb. The etiology of DVT often involves venous stasis, endothelial injury, and hypercoagulability. Pathophysiologically, the clot obstructs venous return, leading to increased venous pressure and potential tissue ischemia. Clinically, patients may present with unilateral leg swelling, tenderness, and warmth. Diagnosis is typically confirmed through imaging studies such as Doppler ultrasound. This diagnosis code is commonly used in emergency medicine settings for patients presenting with symptoms suggestive of DVT.

Key Clinical Considerations:

Diagnosis of Acute DVT requires clinical evidence of venous thrombosis, typically supported by imaging studies.
Signs and symptoms include unilateral leg swelling, pain, tenderness, and warmth over the affected area.
Resolution criteria include the absence of symptoms and normalization of imaging findings after treatment.
Doppler ultrasound is the primary imaging modality used to confirm the diagnosis of DVT.

Clinical Information

Clinical Criteria & Documentation Requirements

Essential documentation includes a detailed history, physical examination findings, and results of imaging studies.
Compliant documentation examples: 'Patient presents with unilateral leg swelling and tenderness; Doppler ultrasound confirms DVT.' Non-compliant: 'Patient has a clot.'
Documentation template phrases include: 'Patient diagnosed with DVT based on ultrasound findings.'
Medical necessity documentation should justify the need for imaging and treatment interventions.

Coding Guidelines

Usage Guidelines & Examples

Use I82.401 for acute DVT of the right leg and I82.421 for the left leg; examples include patients presenting with leg swelling and pain.
Do not use this code for superficial venous thrombosis or chronic venous insufficiency.
Correct usage: 'Patient diagnosed with acute DVT I82.401.' Incorrect: 'Patient has a history of DVT.'
Common coding errors include misidentifying the affected leg; ensure accurate documentation of laterality.

Code Exclusions

Important Exclusions

Excluded conditions include superficial venous thrombosis (I80) and chronic venous insufficiency (I87.2) due to different pathophysiology.
Alternative codes for exclusions include I80.0 for superficial thrombophlebitis.
Common exclusion errors involve misclassifying superficial thrombosis as DVT; ensure accurate clinical assessment.
Certain conditions are excluded to maintain specificity in coding for acute DVT.

Specialty Focus

Primary Specialty

Emergency Medicine

Specialty Applications

This diagnosis applies to patients with acute symptoms suggestive of DVT.
Clinical scenarios include post-operative patients or those with prolonged immobility.
Applicable in various settings including inpatient, outpatient, and emergency departments.
Specialty-specific considerations include the need for urgent imaging and anticoagulation management.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Template: 'DVT diagnosed based on Doppler ultrasound findings.'

Template 2

Template: 'Patient presents with unilateral leg swelling consistent with DVT.'

Template 3

Template: 'Diagnostic criteria met: ultrasound shows thrombus in the right leg.'

Template 4

Template: 'Treatment plan includes anticoagulation therapy for DVT.'

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

What documentation is required for this code?

Detailed documentation includes patient history, physical exam findings, and imaging results.

When should this code be used vs similar codes?

Use this code for acute DVT; similar codes apply to chronic conditions or superficial thrombosis.

What are common billing issues with this code?

Reimbursement issues may arise from lack of supporting documentation; ensure complete records.

What procedures are commonly associated?

Related CPT codes include ultrasound (76930) and anticoagulation management services.

What is Acute Deep Venous Thrombosis?

Key Clinical Considerations:

Diagnosis of Acute DVT requires clinical evidence of venous thrombosis, typically supported by imaging studies.
Signs and symptoms include unilateral leg swelling, pain, tenderness, and warmth over the affected area.
Resolution criteria include the absence of symptoms and normalization of imaging findings after treatment.
Doppler ultrasound is the primary imaging modality used to confirm the diagnosis of DVT.

Acute Deep Venous Thrombosis

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?

Acute Deep Venous Thrombosis

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Template 1

Template 2

Template 3

Template 4

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What documentation is required for this code?

When should this code be used vs similar codes?

What are common billing issues with this code?

What procedures are commonly associated?